Hindawi Publishing Corporation

Evidence-Based Complementary and Alternative Medicine

Volume 2013, Article ID 204259, 12 pages
http://dx.doi.org/10.1155/2013/204259

Research Article
A Longitudinal Study of the Reliability of Acupuncture Deqi
Sensations in Knee Osteoarthritis

Rosa B. Spaeth,1 Stephanie Camhi,2 Javeria A. Hashmi,1 Mark Vangel,3,4 Ajay D. Wasan,5
Robert R. Edwards,5 Randy L. Gollub,1,3 and Jian Kong1,3
1
Department of Psychiatry, Massachusetts General Hospital, Charlestown, MA 02129, USA
2
Department of Psychology, Endicott College, Beverly, MA 01915, USA
3
MGH/MIT/HMS Athinoula A. Martinos Center for Biomedical Imaging, Charlestown, MA 02129, USA
4
Department of Radiology, Massachusetts General Hospital, Charlestown, MA 02129, USA
5
Departments of Anesthesiology, Perioperative and Pain Medicine and Psychiatry,
Brigham and Women’s Hospital and Harvard Medical School, Boston, MA 02115, USA

Correspondence should be addressed to Jian Kong; kongj@nmr.mgh.harvard.edu

Received 26 April 2013; Revised 6 June 2013; Accepted 7 June 2013

Academic Editor: Gerhard Litscher

Copyright © 2013 Rosa B. Spaeth et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Deqi is one of the core concepts in acupuncture theory and encompasses a range of sensations. In this study, we used the
MGH Acupuncture Sensation Scale (MASS) to measure and assess the reliability of the sensations evoked by acupuncture needle
stimulation in a longitudinal clinical trial on knee osteoarthritis (OA) patients. The Knee injury and Osteoarthritis Outcome Score
(KOOS) was used as the clinical outcome. Thirty OA patients were randomized into one of three groups (high dose, low dose,
and sham acupuncture) for 4 weeks. We found that, compared with sham acupuncture, real acupuncture (combining high and
low doses) produced significant improvement in knee pain (𝑃 = .025) and function in sport (𝑃 = .049). Intraclass correlation
analysis showed that patients reliably rated 11 of the 12 acupuncture sensations listed on the MASS and that heaviness was rated
most consistently. Overall perceived sensation (MASS Index) (𝑃 = .014), ratings of soreness (𝑃 = .002), and aching (𝑃 = .002)
differed significantly across acupuncture groups. Compared to sham acupuncture, real acupuncture reliably evoked stronger deqi
sensations and led to better clinical outcomes when measured in a chronic pain population. Our findings highlight the MASS as a
useful tool for measuring deqi in acupuncture research.

1. Introduction acupuncture sensations is that perception of deqi is subjective

Deqi (obtaining qi) is a core concept in traditional Chinese
acupuncture theory [1, 2] that describes the physiological
link between the stimulation of acupuncture needles and
the energy meridians running through the body [2–5]. The
term deqi encompasses numerous sensations (e.g., soreness,
heaviness), the complete range of which is debated [6–8].
Traditional ancient acupuncturists believed that deqi
was comprised of sensations and/or experiences of both
the patient receiving the treatment and the acupuncturist
administering the treatment [7–9]. Modern acupuncturists
and researchers, however, have emphasized the patient’s
sensations rather than the acupuncturist’s experience dur-
ing needling [10–13]. One challenge in investigating these
and the specific sensations associated with deqi may vary
significantly both between and within individuals, which
calls for the development of a systematic measurement of
deqi sensation. To overcome this barrier, in recent years,
investigators have started to use different scales to measure
deqi sensation [2, 10–16] and have investigated the association
between deqi sensation and therapeutic effects [13, 17, 18].
It is generally believed that deqi sensation is crucial for
effective acupuncture treatment, a belief rooted in traditional
Chinese acupunture theory [2]; however, the link between
these sensations and improvements in clinical outcomes
remains unclear [19, 20]. Previous studies investigating the
relationship between deqi sensations and clinical outcomes
are contradictory [21–24]. It is important to note that most
2 Evidence-Based Complementary and Alternative Medicine
studies use deqi as a general construct [25] and that none
of these studies explored the association between clinical
outcomes and specific, quantified sensations [21–24]; rather,
these studies investigated the difference between traditional
Chinese acupuncture (with deqi) and sham acupuncture
(with no or minimal deqi sensation). In a previous study
in healthy subjects, we developed an acupuncture sensa-
tion scale [13] to measure the sensations evoked by elec-
troacupuncture, manual acupuncture, and sham acupunc-
ture. This scale has subsequently been revised, renamed,
and used in other acupuncture research studies including
the present study [2, 26]. In our previous study, we found
that numbness and soreness were significantly associated
with analgesia to experimental heat pain [13]. Nevertheless,
few studies have systematically measured and characterized
deqi sensations in a patient population longitudinally and
explored the association between quantified deqi sensations
and clinical outcomes.
In the present study, we longitudinally investigated
acupuncture treatment-evoked deqi sensations in a chronic
pain population using the Massachusetts General Hospital
(MGH) Acupuncture Sensation Scale (MASS) and explored
the association between deqi sensations and changes in
clinical outcomes related to knee pain. More specifically, knee
osteoarthritis (OA) patients were randomized into one of
three treatment groups: high-dose acupuncture treatment
(application of six acupuncture points), low-dose acupunc-
ture treatment (application of 2 acupuncture points), and
sham acupuncture (Streitberger placebo acupuncture needles
on 6 nonacupoints). We employed a tapered longitudinal
treatment design [21], such that each patient received 6
acupuncture treatments over the course of 4 weeks (2 treat-
ments per week for the first 2 weeks and one treatment per
week for the last 2 weeks). Deqi sensations were measured
using the MASS twice during each treatment. And after
the six-session acupuncture treatment period, the Knee
injury and Osteoarthritis Outcome Score (KOOS) was also
administered to investigate changes in knee pain and function
following treatment with either real or sham acupuncture.
2. Materials and Methods
2.1. Subjects. The Institutional Review Board at the Mas-
sachusetts General Hospital approved all study procedures.
All subjects provided written informed consent at the begin-
ning of the study and were debriefed at the end of the study.
2.2. Patient Recruitment and Inclusion Criteria. Acupunc-
ture naı̈ve patients aged 40–70 with a diagnosis of chronic
painful osteoarthritis (OA) in the right and/or left knee
were recruited for this study, as previous studies have indi-
cated that acupuncture is an effective treatment for patients
with chronic knee pain [21–23]. Investigators excluded
acupuncture-experienced subjects to minimize the possi-
bility of subjects distinguishing sham from real acupunc-
ture, serving to assist in blinding the subjects to their
assigned treatment group. Patients were recruited from the
Massachusetts General Hospital (MGH) and Brigham and
Women’s Hospital (BWH).
Subjects were included if they met the Kellgren-Lawrence
scale for radiographically grading knee OA [27–29] as grade 2
or 3. Those with severe knee OA were excluded. Other specific
inclusion and exclusion criteria were designed to allow for
the retention of a relatively homogenous clinical population;
subjects were excluded for any interventional procedure for
knee pain within 6 months prior to enrolling in the study,
intent to undergo surgery during the time of involvement in
the study, knee pain due to other causes such as inflammation
or malignancy, diagnosis of rheumatoid arthritis or other
pain disorders that may refer pain to the leg, medications
or disorders that would put patients at heightened potential
for adverse outcome, and presence of MRI contraindications
(e.g., cardiac pacemaker, metal implants, claustrophobia, and
pregnancy). All OA patients had an endogenous knee pain
intensity rating (average in the last week) of >2 on a 0 to 10
scale at the first visit.
2.3. Experimental Design. To maintain consistency within
our sample of patients who had both unilateral and bilateral
knee pains, we only treated one knee for each subject. For
those subjects with bilateral knee pain, the knee with the
highest pain ratings was treated. Subjects were stratified by
knee and randomized into one of the three groups: high-dose
real acupuncture (6 acupoints), low dose real acupuncture
(2 acupoints), and high-dose sham acupuncture (6 nonacu-
points with Streitberger placebo needles) (see Figure 1).
2.4. Blinding. At the time of consent, all patients were
informed that they would receive one of three modes of
acupuncture treatment and that there was an equal chance of
receiving each mode of treatment. Using specially designed
placebo needles (described below) and acupuncture-naı̈ve
subjects, we were able to keep all subjects blinded to acupunc-
ture mode (real versus sham acupuncture). Subjects were
not told how many needles would be used in the high-
versus low-dose acupuncture groups. All clinical outcomes
detailed below were measured by research staff, also blinded
to treatment condition; thus, the study was single blinded
(patients and research staff were blinded; acupuncturist was
not blinded).
After an initial screening session, each subject engaged in
a total of 6 acupuncture-treatment sessions, completing the
MASS form twice within each session. Treatments 1, 3, and
6 occurred approximately 15 minutes into a scan session in
which the patient was lying in a 3 Tesla Tim Trio magnetic
resonance imaging scanner (Siemens, Erlangen, Germany)
while functional imaging data was acquired. The remaining
treatments were administered in a behavioral testing room
with patients reclined in a chair. All acupuncture treatments
were completed within four weeks.
2.5. Acupuncture Administration. High- and low-dose
acupuncture groups differed only in the number of acupoints
stimulated. In the high-dose group, 6 needles were inserted at
6 acupoints (see Figure 2(a)), and each point was stimulated
4 times. In the low-dose group, 2 needles were inserted, and
each point was stimulated a total of 12 times. The total length
Evidence-Based Complementary and Alternative Medicine 3

Assessed for
eligibility
(N = 44) Excluded (N = 10)
∙ Scheduling (N = 4)
∙ Ineligibility at screening (N = 3) Xiyan SP 9
∙ Disinterest (N = 2) GB 34
∙ Claustrophobia (N = 1) ST35
Stratified by knee and Sham 1
randomized (N = 34) Sham 1
Sham 2
Sham 2
Sham 3
Sham 3

Allocated to Allocated to Allocated to

low-dose high-dose sham
acupuncture acupuncture acupuncture
(N = 12) (N = 12) (N = 10)
∙ Received ∙ Received ∙ Received
complete complete complete SP 6
intervention GB 39
intervention intervention
(N = 10) (N = 10) (N = 10)
∙ Did not ∙ Did not
receive receive
complete complete
intervention intervention
(N = 2) (N = 2) (a)
10 30 10 30 10 30 10 30 10 30 10 (sec)
Discontinued Discontinued Discontinued Ml M2 M3 M4 M5 M6
intervention intervention intervention Needles in Needles out
∙ Scheduling ∙ Noncompliance
(N = 0)
(N = 2) in scanner
(N = 2) 0 30 s 4 6 9.5 10 15 15.5 19 21 24.5 25(min)
Real/sham acupuncture Real/sham acupuncture
MASS1 MASS2
Analyzed Analyzed Analyzed
(b)
(N = 10) (N = 10) (N = 10)
Figure 2: Standardized acupuncture protocol. (a) Real and sham
Figure 1: Consort diagram indicating the number of patients
acupuncture points. Low-dose real acupuncture was applied on
enrolled, dropped, and completed, by group.
ST35 and Xiyan (extra point). High-dose acupuncture group was
applied to four additional points: GB34, SP9, GB39, and SP6. Six
sham acupuncture points were used for the sham acupuncture
group. (b) Acupuncture stimulation paradigm for both real and
placebo acupunctures, indicating the timeline of intermittent needle
of the treatment remained constant across all treatment stimulation during each acupuncture treatment. Six 10-second
groups. All other treatment parameters, as described below, periods of manual needle rotation (M) were separated by 30 seconds
of rest. The manual stimulation series (M1–6) was repeated a total
were held constant (Figure 2(b)).
of 4 times, twice prior to administering the first MASS, and an
Each acupuncture treatment session for subjects in both additional 2 times prior to the second MASS.
the real and the sham acupuncture groups was about 25
minutes in duration and was carried out by the same licensed
acupuncturist. For all treatments, the acupuncturist located
the acupoints on the leg, disinfected each point with isopropyl
alcohol, and then placed a small plastic ring over the point, The high-dose acupuncture group received treatment at
securing the ring with a thin strip of sterile plastic tape. This four additional points including GB34, SP9, GB39, and SP6
ensured patient blindness to the actual site of needle insertion (see Figure 2(a)).
and thus blindness to whether the treatment was real or sham. For consistency, leg position, acupoint location, and
For all patients, a predetermined number of acupoints (either needling parameters (1-2 cm depth, approximately 120 rota-
2 or 6) were stimulated in a predetermined order for a total tions per minute, 90∘ insertion angle, and moderate deqi
of 24 stimulations (Figure 2(b)). sensations on a 0–10 scale) were kept constant across groups.
Needles were rotated at each point for 10 seconds with
30-second breaks between each point (see Figure 2(b)). All
2.5.1. Real Acupuncture Treatments. For the low-dose points (either 2 or 6 acupoints) were stimulated one point at
acupuncture group, real acupuncture was applied to ST35 a time and were stimulated in a predetermined order. In the
and Xiyan (extra point) (see Figure 2(a)). These two high-dose group, needles were manipulated in the order of
acupuncture points are well documented for treating knee GB34, SP9, ST35, Xiyan (extra point), GB39, and SP6. The
pain according to traditional Chinese acupuncture [9, 30]. specific starting acupoint was randomized across patients,
Both points, located near the knee, have been used in but within patients, the starting point was held constant
previous clinical trials of OA patients [21–23]. across sessions.
4 Evidence-Based Complementary and Alternative Medicine
2.5.2. Placebo Acupuncture Procedures. Placebo acupuncture
was applied at six nonacupoints using Streitberger placebo
needles specially designed for subject blinding [13, 31–35]
using a paradigm identical to the real acupuncture treatment.
These sham needles are visually indistinguishable but differ
from regular needles by virtue of their blunt, retractable tip.
Instead of penetrating the skin, the point of the Streitberger
needle retracts up into the shaft when the acupuncturist
presses it against the skin. This sham device has been
validated by studies showing that subjects cannot distinguish
between real and sham needling [13, 31, 32].
Six sham points were used during placebo acupuncture:
sham point 1 was located 1.5 cun posterior and inferior to
GB34, sham points 2-3 were located 1.5 cun and 3 cun inferior
to sham point 1, sham point 4 was located 1 cun posterior
to the midpoint of K9 and K10, and sham points 5-6 were
located 1.5 cun inferior and superior to the sham point 4
separately (see Figure 2(a)). All sham points were located on
the lower leg where no meridians pass through. Placebo treat-
ment administration was similar to high-dose acupuncture
administration with regard to the number of acupoints.
2.6. Clinical Outcomes
2.6.1. Knee Injury and Osteoarthritis Outcome Score (KOOS).
The Knee injury and Osteoarthritis Outcome Score (KOOS)
[36] was used to measure clinical outcomes. The KOOS is
comprised of 5 subscales, each of which produces an outcome
score. These subscales include pain, other symptoms, func-
tion in daily living (ADL), function in sport and recreation,
and knee-related quality of life (QOL). Based on previous
studies, subscale scores of the KOOS related to pain, function
in daily living, and function in sport and recreation were
selected as the primary outcome of the present study [21].
Other subscores were used for exploratory analyses. Trained
research assistants, blinded to treatment mode, administered
the KOOS to all patients at baseline (within one week of
the first treatment) and at the final (sixth) treatment. For
each subscale, a normalized score was calculated, where 0
indicated the most extreme symptoms/pain and 100 indicated
no symptoms/pain [36].
2.6.2. Massachusetts General Hospital Acupuncture Sensation
Scale (MASS). The Massachusetts General Hospital (MGH)
Acupuncture Sensation Scale (MASS) [2] is the revised
version of the Subjective Acupuncture Sensation Scale that
has been used in previous studies in healthy subjects [13].
This scale includes 12 descriptors (soreness, aching, deep
pressure, heaviness, fullness/distension, tingling, numbness,
sharp pain, dull pain, warmth, cold, and throbbing) that
are considered to be associated with acupuncture treatment
and one supplementary field for subjects to describe the
acupuncture sensation in their own words [2]. Subjects were
asked to rate the intensity of each sensation on a scale from
0 to 10, where 0 is none and 10 is unbearable. This scale was
created through a collaboration of acupuncture researchers at
the MGH Martinos Center and has been used by acupuncture
researchers since 2007 [26, 37]. The MASS has subsequently
been translated and validated in Chinese [38].
All subjects were asked to rate their acupuncture sensa-
tions using the MASS twice during each treatment. Subjects
were asked to report the average sensation across all of the
needles used for their treatment (either 2 or 6, depending
on the group). Prior to the first treatment, the acupuncturist
gave all subjects a brief description of deqi, as subjects were
acupuncture naı̈ve upon enrollment. Each subject was told
the following: “The MGH Acupuncture Sensation Scale lists
12 of the sensations commonly reported by people who
receive acupuncture. Different patients experience different
sensations, and you might not experience all of the sensations.
If you feel a sensation that is not listed here, you may write in
the sensation you feel and indicate how intensely you felt that
sensation.” The MASS was used to measure average sensations
during needle stimulation across each 10-minute treatment
period. After the first block of intermittent acupuncture
stimulation (see Figure 2(b)), subjects were asked to indicate
the extent to which each of the 12 descriptors described their
subjective acupuncture experiences. Subjects were asked to
repeat this assessment again after the second 10-minute block
of intermittent stimulation.
The MASS index is a measure that describes the overall
magnitude of deqi sensation experienced during treatment.
Using previously described methods [2], the index was
calculated by ranking all of the sensations by self-reported
intensity ratings (0–10) and then assigning a weight to each
sensation based on rank.
2.7. Data Analysis. Statistical analyses were performed using
SPSS 18.0 Software (SPSS Inc., Chicago, IL, USA). Variance in
baseline characteristics, intensity ratings of each individual
sensation, the overall sum of all sensations, and the MASS
index across treatment modalities were analyzed using a one-
way ANOVA and post hoc t-tests (𝑃 < .05) and were
corrected for multiple comparisons. All confidence intervals
(CIs) are reported at the 95% confidence level.
The MASS index, a weighted average of the intensity of
sensations elicited, was calculated using previously published
methods [2]. In brief, for each administration of the MASS (12
per subject), the deqi sensation descriptors (soreness, aching,
etc.) were ordered from the highest to the lowest subjective
intensity rating. As previously suggested, ratings of sharp
pain were excluded from the MASS index calculation, as
sharp pain is not always considered a deqi sensation. Using
exponential smoothing, a weighted average (MASS index)
was calculated.
The internal consistency reliability of the MASS scale
was computed and results are presented as Cronbach’s alpha.
Measures of the test-retest reliability of each individual
sensation, the overall sum of all sensations, and the MASS
index were computed using intraclass correlation coefficients.
To compare how frequently each sensation was rated ≥1 on
a scale from 0 to 10 across the 3 groups, a chi-square test
for independence was conducted for each sensation. For
each chi-square test, we compared the number of people
who reported that sensation at least once throughout the 6
treatments across the three groups.
Factor analysis was performed using the principal
component extraction method to segment acupuncture
Evidence-Based Complementary and Alternative Medicine
Table 1: Baseline characteristics.
Mean ± SD All
N 30
Gender 13 Females
Age 57.5 ± 8.3
Duration (treated knee, years)∗ 10.5 ± 8.3
KOOS pain 55.94 ± 14.10
KOOS symptoms 52.98 ± 16.17
KOOS ADL 63.58 ± 15.34
KOOS sport† 29.48 ± 22.92
KOOS QOL 38.75 ± 15.25
Significant main effect of group (high versus low versus sham) indicated by ∗ ; † indicates 𝑁 = 29 due to one missing KOOS subscale score (low-dose group).
sensations (MASS) into meaningful clusters. Component
extraction was based on eigenvalues greater than 1.0 with
no specifications for a fixed number of factors to extract.
A Varimax rotated solution with 25 maximum iterations
for convergence was analyzed. Factors were loaded with a
cut-off value of 0.4 (representing 16% variance). Pearson’s
correlations were applied to examine the potential relation-
ship between osteoarthritis treatment outcomes (KOOS) and
the perceived intensity of select sensations identified by the
principal component analysis (PCA).
3. Results
Forty-four (19 females) acupuncture naı̈ve patients aged 43–
70 with a diagnosis of chronic painful osteoarthritis in the
right and/or left knee enrolled in the study. Of the 44
patients who enrolled, 30 (13 females) completed all study
procedures. Ten of the 14 patients who did not complete all
study procedures dropped out prior to the first treatment
due to ineligibility at screening (3), scheduling conflicts (4),
claustrophobia (1), and lack of interest (2); the remaining 4
patients who underwent at least one acupuncture treatment
session dropped out for the following reasons: scheduling
conflicts (2, low-dose group) and inability to adhere to study
requirements in scanner (2, high-dose group) (see Figure 1).
3.1. Clinical Outcomes. Of the 30 patients who completed all
study procedures, 20 were treated on their right knee, and
10 were treated on their left knee. Baseline characteristics are
detailed in Table 1. One subject in the low-dose acupuncture
group did not complete the KOOS subscale for function in
sport; thus, for all analyses including the KOOS function in
sport variable only complete datasets (𝑁 = 29) were used.
Repeated measurements analysis of pre- and post-
treatment knee pain across three groups revealed a significant
effect of time (baseline versus endpoint) on the KOOS
subscales for pain (𝐹(1, 28) = 9.661, 𝑃 = .004, and 95%
CI [2.75, 13.34]), function in daily living (ADL) (𝐹(1, 28) =
8.310, 𝑃 = .007, and 95% CI [2.61, 13.92]), and function
in sport (𝐹(1, 28) = 6.145, 𝑃 = .0019, and 95% CI [2.04,
21.41]). A trend was observed for the interaction between
group and time on the KOOS pain subscale score (𝐹(2, 27) =
2.709, 𝑃 = .085) but not for either function in daily living
5
High dose Low dose Sham
10 10 10
2 Females 7 Females 4 Females
60.1 ± 8.9 58.30 ± 8.6 54.1 ± 7.3
9.8 ± 7.4 5.7 ± 6.0 16.22 ± 8.3
58.61 ± 12.99 53.09 ± 9.39 56.11 ± 19.15
57.14 ± 19.12 48.21 ± 10.68 53.57 ± 17.82
66.03 ± 11.83 61.18 ± 13.83 63.53 ± 20.34
30.00 ± 18.11 31.16 ± 19.06 28.50 ± 30.92
41.88 ± 16.94 38.13 ± 13.96 36.25 ± 15.81
(𝐹(2, 27) = 2.178, 𝑃 = .133) or function in sport (𝐹(2, 26) =
2.047, 𝑃 = .149) (see Figure 3(a)). Post hoc tests indicated no
significant differences between the high- and low-dose real
acupuncture groups for pain (𝑃 = .612), function in daily life
(𝑃 = 1.0), and function in sport (𝑃 = 1.0).
To increase power in our analysis, we combined the two
real acupuncture groups (high and low dose) to compare
real acupuncture (𝑁 = 20) to sham acupuncture (𝑁 =
10). The results indicated a significant interaction between
acupuncture mode (real versus sham) and time (baseline
versus endpoint) on our primary outcomes: the KOOS
subscale scores for pain (𝐹(1, 28) = 5.596, 𝑃 = .025) and
function in sport (𝐹(1, 27) = 4.252, 𝑃 = .049). In addition,
we found that our secondary outcome (KOOS subscale score
for quality of life (QOL)) showed significant improvement in
the real acupuncture group after treatment compared with
the sham group (𝐹(1, 28) = 4.682, 𝑃 = .039) (see Figure 3(b)).
3.2. Acupuncture Deqi Sensations. In this study, subjects
reported deqi sensations at 2 different time points in each
treatment session: after the first 10-minute acupuncture
stimulation period and again after the second 10-minute
acupuncture stimulation period (see Figure 2(b)). In total,
30 subjects completed 6 treatment sessions, and all but one
subject completed the MASS twice per treatment. For one
subject, the second deqi assessment was missing from 3
treatment sessions. For the internal consistency reliability
analysis of the MASS, only complete data sets were used. For
all other analyses, the first and second administrations of the
MASS in each treatment were averaged for each sensation.
3.2.1. Internal Consistency Reliability of the MGH Acupuncture
Sensation Scale (MASS). The Cronbach’s alpha reliability of
the 12 items in the MASS was calculated for each admin-
istration of the MASS (twice per treatment session) and
ranged from 0.856 to 0.948 (see Table 2 for complete list of
Cronbach’s alphas).
3.2.2. Test-Retest Reliability of Deqi Sensation across Different
Treatment Modes. Intraclass correlation analysis showed that
patients rated soreness, aching, deep pressure, heaviness,
fullness/distension, tingling, numbness, sharp pain, dull pain,
warmth, and throbbing reliably across all 6 sessions (ICC
6 Evidence-Based Complementary and Alternative Medicine

Change in KOOS subscale scores Change in KOOS subscale scores

30

20
20
Mean change (post-pre)

Mean change (post-pre)

10 10

0 0

−10
−10

−20
Sham Real (low) Real (high) Sham Real
Acupuncture dose Acupuncture mode
Pain Sport Pain Sport
Symptoms QOL Symptoms QOL
Function Function
Error bars: +/−1 SE Error bars: +/−1 SE
(a) (b)

Figure 3: Changes in KOOS subscale scores from baseline to endpoint. Improvement in each of the 5 domains is indicated by a positive
value. (a) The interaction between group (high versus low versus sham) and time (baseline versus endpoint) showed a trend for the KOOS
pain subscale (𝐹(2, 27) = 2.709, 𝑃 = .085) but not for either function in daily living (𝐹(2, 27) = 2.178, 𝑃 = .133) or function in sport
(𝐹(2, 26) = 2.047, 𝑃 = .149). (b) The interaction between group (real versus sham) and time (baseline versus endpoint) was significant for
the KOOS subscale scores for pain (𝐹(1, 28) = 5.596, 𝑃 = .025), function in sport (𝐹(1, 27) = 4.252, 𝑃 = .049), and quality of life (QOL)
(𝐹(1, 28) = 4.682, 𝑃 = .039).

Table 2: Internal consistency of the 12-item MGH acupuncture cold sensation. Both the sum score and the MASS index
sensation scale (MASS). were highly reliable across all subjects and within each group
(see Table 3 for complete list of all intraclass correlation
Administration 1 Administration 2
coefficients).
Treatment 1 .891 .909
Treatment 2 .948 .963†
3.2.3. Intensity of Sensations. Across all 30 patients, the
Treatment 3 .913 .856
sensations that were rated with the highest intensity in
Treatment 4 .868 .880† response to treatment included soreness, dull pain, and sharp
Treatment 5 .893 .907† pain. Those rated at the lowest intensity included cold and
Treatment 6 .875 .878 warmth. Descriptive statistics for each sensation are listed in
All measures of the internal consistency of the MASS administered to 30 Table 4.
subjects are reported as Cronbach’s alpha; 𝑁 = 29 due to missing data set After Bonferroni corrections for multiple comparisons
indicated by †. (𝑃 < .0038), intensity ratings of soreness (𝐹(2, 27) = 7.74,
𝑃 = .002) and aching (𝐹(2, 27) = 7.55, 𝑃 = .002)
differed significantly across treatment groups (high versus
ranged from .928 to .768). In short, 11 of the 12 sensations low versus sham). Post hoc comparisons of soreness and
on the MASS were rated reliably with the exception of cold aching demonstrated that there was no significant difference
(ICC = .078, 𝑃 = .37), and heaviness was rated most reliably between the high- and low-dose real acupuncture groups and
across all sessions (ICC = .928, 𝑃 < .001). that those subjects in the sham group reported significantly
Further analysis of each treatment group indicated that, less soreness and aching as compared to the high-dose (𝑃 =
in the high-dose acupuncture group, heaviness (ICC = .88, .01 and 𝑃 = .05, resp.) and low-dose (𝑃 = .003 and 𝑃 =
𝑃 < .001) was rated the most reliably. In the low-dose .002, resp.) acupuncture treatment groups. Reported intensity
acupuncture group, deep pressure (ICC = .943, 𝑃 < .001) ratings for each individual sensation are depicted in Table 4.
and fullness/distention (ICC = .943, 𝑃 < .001) were To further elucidate the differences between real and
rated the most reliably. In the sham acupuncture treatment sham acupuncture, data from the low- and high-dose
group, numbness was rated most reliably (ICC = .932, acupuncture groups were pooled to increase power. After
𝑃 < .001). None of the treatment groups reliably rated the correction for multiple comparisons (𝑃 < .0038), sensations
Evidence-Based Complementary and Alternative Medicine 7

Table 3: Test-retest reliability of deqi sensations.

All High Dose Low Dose Sham

Soreness .889 (<.001) .721 (.002) .925 (<.001) .688 (.004)
Aching .913 (<.001) .726 (.002) .922 (<.001) .777 (<.001)
Deep pressure .903 (<.001) .808 (<.001) .943 (<.001) .821 (<.001)
Heaviness .928 (<.001) .88 (<.001) .926 (<.001) .769 (<.001)
Fullness/distention .921 (<.001) .831 (<.001) .943 (<.001) .872 (<.001)
Tingling .839 (<.001) .848 (<.001) .795 (<.001) .81 (<.001)
Numbness .861 (<.001) .839 (<.001) .837 (<.001) .932 (<.001)
Sharp pain .768 (<.001) .486 (.069) .812 (<.001) .761 (.001)
Dull pain .845 (<.001) .583 (.026) .874 (<.001) .871 (<.001)
Warmth .74 (<.001) .664 (.007) .661 (.008) .894 (<.001)
Cold .078 (.37) .467 (.08) −.052 (.493) −.15 (.559)
Throbbing .792 (<.001) .774 (<.001) .601 (.02) .876 (<.001)
Other .681 (<.001) −.75 (.508) .641 (.011) .741 (.001)
Sum .907 (<.001) .792 (<.001) .922 (<.001) .901 (<.001)
Mass index .907 (<.001) .764 (.001) .927 (<.001) .902 (<.001)
All test-retest reliability analyses reported as intraclass correlation coefficients (𝑃 value).

Table 4: Comparison of intensity ratings and MASS Index across acupuncture treatment groups.

All High Dose Low Dose Sham

Soreness∗ 1.29 ± 1.21 1.69 ± .86 1.89 ± 1.47 .28 ± .34
Aching∗ 1.09 ± 1.14 1.25 ± .8 1.83 ± 1.4 .2 ± .3
Deep pressure 1.05 ± 1.13 1.1 ± .98 1.51 ± 1.53 .55 ± .57
Heaviness .80 ± 1.12 .67 ± .94 1.54 ± 1.42 .2 ± .25
Fullness/distention .71 ± 1.04 .68 ± .86 1.25 ± 1.42 .18 ± .38
Tingling 1.21 ± 1 1.61 ± 1.21 1.26 ± 1 .77 ± .64
Numbness .70 ± .87 .82 ± .89 .96 ± 1.01 .33 ± .61
Sharp pain 1.43 ± 1.05 1.9 ± .84 1.63 ± 1.25 .76 ± .71
Dull pain 1.35 ± 1.1 1.55 ± .78 1.85 ± 1.38 .65 ± .73
Warmth .48 ± .59 .4 ± .63 .66 ± .54 .38 ± .62
Cold .06 ± .15 .06 ± .13 .11 ± .22 .02 ± .04
Throbbing∗ .63 ± .81 1.13 ± 1.1 .63 ± .53 .15 ± .32
Other .19 ± .34 .08 ± .19 .12 ± .19 .37 ± .49
Sum score∗ 10.99 ± 9.3 12.95 ± 7.55 15.22 ± 11.9 4.82 ± 3.79
MASS index∗ 1.62 ± 1.13 1.96 ± .84 2.10 ± 1.38 .80 ± .62
Values presented as mean ± standard deviation. Significant differences between acupuncture mode (real versus sham acupuncture) after correction for multiple
comparisons indicated by ∗.

of soreness (𝑃 < .001), aching (𝑃 < .001), and throbbing
(𝑃 = .003) were rated significantly more intensely in the
real acupuncture group compared to the sham acupuncture
group.
The average total MASS score (sum of the intensities of
each sensation) differed significantly across the acupuncture
treatment groups (high versus low versus sham) (𝐹(2, 27) =
4.21, 𝑃 = .026). Similarly, the MASS index, or overall
perceived sensation of acupuncture, differed significantly
across the acupuncture treatment groups (𝐹(2, 27) = 5.03,
𝑃 = .014). Those who received sham acupuncture had a
significantly lower MASS index and total MASS score than
those who received either high-dose (𝑃 = .04 and trend 𝑃 =
.1, resp.) or low-dose (𝑃 = .02 and 𝑃 = .03, resp.) acupuncture
treatments. No significant difference was observed between
high- and low-dose acupuncture groups for the MASS Index
(𝑃 = .949) or the total MASS score (𝑃 = .617).
3.2.4. Frequency of Sensations. A chi-square test for inde-
pendence indicated that there was a significant effect of
acupuncture dose (high versus low versus sham) on the
number of individuals reporting soreness (𝜒2 (2, 𝑁 = 30)
= 6.24, 𝑃 = .044) and that there was a trend for aching (𝜒2
(2, 𝑁 = 30) = 5.96, 𝑃 = .051) and fullness/distension (𝜒2 (2,
𝑁 = 30) = 5.83, 𝑃 = .054). Further comparisons between
acupuncture modes (real versus sham) indicated that there
was a significant effect of acupuncture mode on frequency of
8 Evidence-Based Complementary and Alternative Medicine

Table 5: By sensation, the number of individuals in each group who Table 6: Results of principal component analysis.
reported the sensation at least once across a total of 6 treatment
sessions (assessed twice per treatment). Variable Factor 1 Factor 2
Heaviness .90 —
All High dose Low dose Sham
Fullness/distension .87 —
Soreness∗ 25 10 9 6 Dull pain .81 —
Aching∗ 21 9 9 5 Cold .81 —
Deep pressure 27 9 10 8 Deep pressure .75 .55
Heaviness 20 7 7 6 Soreness .75 .40
Fullness/distention∗ 18 8 7 3 Aching .75 .55
Tingling 26 10 8 8 Numbness .60 .56
Numbness 20 7 7 6 Sharp pain .54 .71
Sharp pain 28 10 10 8 Warmth .42 .49
Dull pain 28 10 10 8 Throbbing — .95
Warmth 17 5 8 4 Tingling — .85
Cold 8 3 3 2
Throbbing 18 7 7 4
Other 11 2 4 5 Due to the similarity between high- and low-dose
Sensations with significantly different frequencies across groups (real versus acupuncture with regard to intensity of sensations, we
sham acupuncture) are denoted with a ∗. grouped the subjects receiving real acupuncture (both high
and low dose) and added acupuncture mode (real or sham
acupuncture) as a variable in our model to determine whether
reporting soreness, aching, and fullness/distension (𝑃 < .05). any of the sensations elicited were related to a single mode
The total number of individuals reporting each sensation is of acupuncture. The results of the PCA using acupuncture
listed in Table 5. mode as an additional variable identified three components
A one-way ANOVA comparing the total number of with eigenvalues greater than 1.0, accounting for a total of
sensations reported by each subject across treatment groups 82% of variance (see Table 7). The KMO measure of sampling
(high versus low versus sham) revealed a trend in the effect of adequacy was .824, and Bartlett’s test of sphericity was
acupuncture dose (𝐹(2, 27) = 2.68, 𝑃 = .087). Further com- significant (𝜒2 (78) = 396.50, 𝑃 < .001), again indicating that,
parison of the real and sham acupuncture treatment groups after including acupuncture mode, the data were still suitable
using an independent sample t-test (equal variances not for factor analysis. Again, variables related to localized deep
assumed according to Levene’s test for equality of variance) pressure sensations loaded onto the first factor, and variables
showed that those who received real acupuncture reported related to spreading sensations loaded onto the second
significantly more sensations during treatment (𝑡(25.37) = factor. Two complex variables (aching and soreness) loaded
−2.65, 𝑃 = .014) compared to the sham acupuncture group. onto the third factor with acupuncture mode, providing
Subjects who received real acupuncture reported an average further evidence that aching and soreness are associated with
of 5.79 ± 3.27 (mean ± SD) sensations during each treatment, acupuncture mode (real versus sham).
while those who received sham reported experiencing 3.12 ±
2.19 sensations. 3.2.6. Relation to Clinical Outcomes. To explore the relation-
ship between acupuncture sensations and clinical outcomes,
3.2.5. Principal Component Analysis. To further investigate we performed Pearson’s correlation analyses on the MASS
the clustering of deqi sensations, principal components anal- index and KOOS subscales across all three groups. Results
ysis (PCA) with Varimax rotation of components and Kaiser showed that there were no significant correlations between
normalization was applied to the acupuncture sensations the overall perceived intensity of sensations (MASS index)
for all subjects. Two components with eigenvalues greater and changes (baseline versus endpoint) in any of the subscales
than 1.0 were identified, accounting in total for 77.4% of of the KOOS. For exploratory purposes, we also performed
the variance. In this analysis, we used a factor loading a PCA to model whether specific sensations were related to
cutoff of 0.4. The Kaiser-Meyer-Olkin (KMO) measure of each subscale of the KOOS. For the pain and QOL subscales,
sampling adequacy was .824, and Bartlett’s test of sphericity two components were identified with eigenvalues greater
was significant (𝜒2 (66) = 385.65, 𝑃 < .001) indicating than 1.0 with a factor loading cutoff of 0.4, and for symptom,
that the data were suitable for factor analysis. While some ADL and sport, three components were identified. For each
variables loaded on a single factor, other variables loaded on of the KOOS subscales, the KMO measure of sampling
both factors, providing evidence of the complex nature of adequacy ranged from 0.802 to 0.819, and all Bartlett’s tests
some of the sensations (see Table 6). The variables loading of sphericity were significant (𝑃 < .001) indicating that the
onto a single factor can be characterized either by deep additional variables were suitable for factor analysis. Changes
pressure sensations (heaviness, fullness/distension, dull pain, in both pain and QOL loaded onto a factor with tingling,
and cold) or sensations related to “spreading sensations” throbbing, and sharp pain. For changes in function in daily
(tingling, throbbing). living and in sport, the acupuncture sensations loaded onto
Evidence-Based Complementary and Alternative Medicine 9

Table 7: Results of principal component analysis with acupuncture In this study, the average deqi sensation was of relatively
mode (real versus sham) included as an additional variable. weak intensity compared to previously reported acupuncture
sensations [26, 39]. For the present study, the average inten-
Variables Factor 1 Factor 2 Factor 3
sity for each sensation was between .06 and 1.89, compared
Heaviness .90 — —
to our previous studies, where average intensity of each
Fullness/distension .88 — — sensation was between 0 and 4 [26] and between 0.1 and 3.7
Deep pressure .78 .54 — [39]. We believe that this may be due to the age of patients in
Cold .78 — — the present study (58 ± 8.3) compared to studies conducted
Dull pain .77 — — in healthy, young subjects (29 ± 7 [26] and 26.4 ± 4.9 [39]).
Aching .70 .485 .42 We speculate that one difference between these populations is
Soreness .66 — .56 that the peripheral nervous system in these older patients may
Numbness .64 .58 — not be as sensitive as other younger populations. Additionally,
Warmth .52 .60 — we note that there are differences in the specific acupoints
needled and the disorder treated in this study compared to
Sharp pain .50 .64 —
previous studies, which may also influence the intensity of the
Throbbing — .91 —
sensations reported.
Tingling — .80 — In this study, knee OA patients across all treatment groups
Acupuncture mode (real versus sham) — — .81 tended to report soreness, deep pressure, tingling, dull pain,
and sharp pain, among others, all of which are typical deqi
sensations based on traditional Chinese medicine. Compared
two different factors, and the KOOS subscale score loaded with real acupuncture, sham acupuncture using a placebo
onto a third factor with a negative correlation with warmth. needle evoked very mild sensations, implying that superfi-
For changes in symptoms, the KOOS subscale score did not cial stimulation may be associated with different subjective
load onto a component with any of the sensations, indicating sensations than deep tissue stimulation. This is consistent
that it did not covary with any of the sensations (see Table 8 with previous studies that reported greater deqi sensations in
for the results of the PCA with each KOOS subscale included real compared to placebo acupuncture [20]. In the present
as an additional variable). study, soreness and aching were reported as significantly
Post hoc tests were conducted to verify the associations more intense in the real acupuncture group compared to the
indicated by the PCA between the MASS sensations and each sham acupuncture group.
subscale of the KOOS that loaded together. This exploratory Our results showed that sensations were equally reliable
analysis revealed a significant correlation between the inten- in the low-dose real acupuncture group as they were in
sity of the throbbing sensation and endpoint QOL subscale the sham acupuncture group, but less reliably in the high-
of the KOOS controlling for baseline QOL score (𝑟 = .477, dose real acupuncture group. This may be due to the fact
𝑃 = .009) as well as the intensity of the tingling sensation and that subjects were asked to report their average sensations
the QOL subscale score at endpoint controlling for baseline across all of the needles, and the number of needles differed
QOL (𝑟 = .368, 𝑃 = .049). No other comparisons were between groups. For the low-dose acupuncture group, sub-
significant when Pearson’s correlations were tested. jects reported the average intensity of each sensation across
two needles; however, for the high-dose acupuncture group,
subjects reported the average intensity of each sensation
3.3. Blinding. At the end of the study, all subjects were across all 6 needles, which is a complex task that could add
asked to complete a set of final questions to assess how additional variability to the data. For the sham acupuncture
well subject blinding was maintained throughout the study. group, subjects reported fewer sensations in total, meaning
Ninety percent (𝑁 = 27) of the subjects believed that the that there was less room for variability in the repeated report
needle was inserted into the skin in every session. The 3 of sensations.
subjects who believed that the needle was not inserted were Overall, the most reliably rated sensation was heaviness,
in the real acupuncture (low dose) group. and the least reliably rated sensation was coldness. We suspect
that the reliability of the sensations may be related to the
4. Discussion disorder studied (in this case, knee OA). Some experts believe
that the exact deqi sensations elicited are specific to the
In this longitudinal clinical trial, we investigated the descrip- physical conditions or the properties of the disorder [6]. It is
tive nature of deqi in knee OA patients. We found that in not surprising that cold sensations were rated the least reliably
real acupuncture treatment, soreness, deep pressure, dull because they were also rated the least frequently. Sensations
pain, and sharp pain were the most frequently reported such as coldness are generally included in acupuncture
sensations. The intraclass correlation analysis indicated that sensations scales because coldness and warmth are two of
most of the sensations on the MASS (with exception of cold) the earliest sensations described in the ancient literature and
were reported reliably across different treatment sessions, are symptom specific [2]. For some disorders that present
implying that the deqi sensation can be reliably measured with symptoms such as fever, acupuncture can produce cold
within subjects using scales such as MASS in a chronic pain sensations to counterbalance these symptoms. The knee OA
population. patients in our study did not tend to report these symptoms
10 Evidence-Based Complementary and Alternative Medicine

Table 8: Results of principal component analysis with the KOOS subscales included as additional variables.

Pain Symptom ADL Sport QOL

1 2 1 2 3 1 2 3 1 2 3 1 2
KOOS — .65 — — .96 — — −.84 — — −.74 — .76
Soreness .81 — .76 — — .78 — — .80 — — .83 —
Aching .87 — .76 .53 — .76 .54 — .76 .54 — .86 —
Deep pressure .88 — .77 .53 — .72 .57 — .70 .55 — .87 —
Heaviness .95 — .91 — — .84 — — .83 — — .93 —
Fullness distension .93 — .88 — — .81 — — .79 — — .91 —
Tingling .47 .72 — .85 — — .82 — — .81 — .46 .73
Numbness .76 — .62 .55 — .54 .57 — .53 .56 — .78 —
Sharp pain .74 .50 .56 .70 — .59 .68 — .62 .67 — .73 .51
Dull pain .87 — .82 — — .82 — — .82 — — .86 —
Warmth .59 — .45 .47 — — .55 .52 — .54 .69 .56 —
Cold .73 — .81 — — .87 — — .88 — — .75 —
Throbbing — .84 — .95 — — .94 — — .92 — — .86

during the acupuncture treatment. We speculate that this may
be the reason for few patients reporting cold sensations.
The characterization of deqi sensations is useful for high-
lighting the differences between real and sham acupuncture
experiences. Using a principal component analysis (PCA),
we were able to segment the acupuncture sensations into
meaningful categories. The results of this study indicate
that deqi sensations on the MASS fall into one and/or two
categories. One category of sensations we observed includes
those sensations related to localized deep pressure. Sensations
such as heaviness, fullness/distension, dull pain and cold
are common traditional Chinese acupuncture sensations and
have previously been reported in relation to deep tissue
stimulation [40]. The other category of sensations identified
by the PCA includes those sensations related to “spreading
sensations” (such as tingling and throbbing). Both of these
components are important factors in traditional Chinese
acupuncture. The remaining sensations loaded onto both
factors and can be viewed as a combination of the two
factors. These results are in line with previous studies which
have found that certain acupuncture sensations with similar
characteristics tend to cluster together [9, 10].
Using the PCA, we were also able to conduct an additional
analysis to identify which of the acupuncture sensations
might be related to acupuncture mode (real versus sham
acupuncture) and to clinical outcomes (KOOS). The present
study suggests that patients in the real acupuncture groups
report sensations such as soreness and aching significantly
more intensely compared to patients in the sham acupunc-
ture group. Exploratory component analyses indicated that
tingling and throbbing may be associated with improvements
in clinical outcomes.
Researchers continue to debate whether certain sensa-
tions or the perceived intensity of those sensations are related
to clinical outcomes [17, 20–24]. In this study, we found that
real acupuncture, which produced stronger deqi sensations,
could also produce significant improvement in pain and
function compared with sham acupuncture. This result is
consistent with previous studies that indicate that stronger
deqi sensation can produce better clinical outcomes [21, 22,
24]. In exploratory analyses, we found that tingling and
throbbing were related to clinical outcomes. It is important
to note, however, that these analyses are highly exploratory
in nature due to small sample size and are not corrected for
multiple comparisons. Specific investigation of the relation-
ship between clinical outcomes and deqi sensations is needed
to further confirm these findings.
In an earlier study by Takeda and colleagues, researchers
investigated the effect of real and sham acupunctures on
osteoarthritis (OA) and found that the experience of deqi
can be used as a predictor for significant improvement
[17]. In four subsequent OA studies comparing the effect
of real acupuncture treatment to sham (minimal depth
needling) acupuncture, three studies [21, 22, 41] found that
real acupuncture produced significantly better therapeutic
effects than sham acupuncture. The fourth study [23] showed
no significant difference between real and sham acupuncture
treatments and further concluded that “deqi sensation[s] do
not result in marked effect,” which calls into questioning
“whether deep needling with stimulation and deqi sensation
is superior to shallow needling.”
One potential limitation of this study is the small sample
size. We believe, however, that this data will provide the basis
for a power analysis of larger clinical trials in the future.
5. Conclusion
In the present longitudinal treatment study, we found that
patients with knee OA reliably reported sensations such as
heaviness, fullness/distension, aching, and deep pressure that
are in coherence with the traditional Chinese acupuncture
theory. Compared with sham acupuncture, real acupuncture
tends to produce stronger deqi sensation and better clini-
cal outcomes. Soreness and aching were implicated as the
two key sensations that differentiate real acupuncture with
needle insertion from superficially stimulated acupuncture.
Evidence-Based Complementary and Alternative Medicine
Elucidation and characterization of the deqi sensation among
patients population may shed new light on our understanding
of the mechanism of acupuncture treatment.
Conflict of Interests
The authors declare that they have no conflict of interests.
Acknowledgments
This work was supported by R21AT004497 (NCCAM),
R03AT218317 (NIDA), and R01AT006364 (NCCAM) to Jian
Kong, R01AT005280 (NCCAM) to Randy Gollub, and P01
AT006663 to Bruce Rosen.
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